Infants born prematurely or with complex congenital abnormalities are surviving to discharge in growing numbers and often require significant monitoring and coordination of care in the ambulatory setting. These complicated infants have spent all of their lives in the hospital setting, and are strangers in their own homes. Although the transition of the fragile child from intensive care specialist to the ambulatory care provider begins at hospital discharge, it is incomplete until the child receives appropriate outpatient follow-up with a primary care pediatrician. Over this prolonged time period, the child is especially vulnerable to errors related to breakdowns in care coordination and communication because the responsibility for the patient's care is often not clearly specified. Our team of investigators has recently completed a Health Care Failure Modes and Effects Analysis (HFMEA) of the transition from neonatal intensive care to the ambulatory environment. In this application, we will target the high-risk processes identified by the HFMEA and evaluate interventions to decrease the risk of poor outcomes in the transition from the Neonatal Intensive Care Unit (NICU) to outpatient follow-up. The specific aims of this project are: 1)To reduce the risk of care transition from the neonatal intensive care nurseries to ambulatory follow-up by redesigning the discharge process and targeting critical error points identified in our recent HFMEA;2)To determine the effectiveness of the redesigned discharge process to improve health outcomes in the post discharge follow-up period as compared with usual care;and 3) To develop a package of materials (a toolkit) that is generalizable to other institutions that care for fragile newborn infants. This toolkit will include a version of the Care Transitions Measure that is validated for use in a pediatric population. We will expand upon the Care Transitions Intervention developed by Coleman et al that addressed the problems of older adults who were discharged from hospital to home. In this model, advanced practice nurses, trained as coaches, taught patients and families to coordinate care for themselves, fostering independence. Second, we will design a standardized discharge process that will include the use of a personal health record, to include specific instructions to recognize and self-manage the most common problems in this population. Third, we will use information technology (IT) to enhance communication with families and with community providers, in particular the primary care provider. Health IT has the potential to facilitate communication and coordination of care between several disciplines and settings of ambulatory care. Having identified that lack of knowledge and skills on the part of community providers about how to manage these infants as an important risk point, we will add to the Coleman intervention by providing "just-in-time" information to the primary care providers to enhance their knowledge and skill in managing the common problems of neonatal nursery graduates, provided electronically via the Texas Children's Hospital (TCH) clinical decision support program. Hence, our interventions will address all the necessary structural and process elements needed to achieve a safe discharge for the fragile infant. PUBLIC HEALTH RELEVANCE: Infants born prematurely or with complex congenital abnormalities are surviving to discharge in growing numbers. During the transition to ambulatory care these infants are especially vulnerable to errors related to breakdowns in care coordination and communication. Based on our recently completed proactive risk assessment, we will implement a package of interventions to address all the necessary structural and process elements needed to achieve a safe passage for the fragile infant from the Neonatal Intensive Care Unit to ambulatory follow up.